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NC Department of Health and Human Services
NC Division of Public Health
 N.C. Public Health Home
 
 

Forms

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 Administration

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Authorization of Fees for Expert Speaker (DPH Travel Workbook) XLS, 547 KB 10/06/11 Addendum to "Conference Authorization Form" - Authorization of Fees for Expert Speaker. Download 2011 workbook containing forms for travel reimbursement and tab to the form you need.
Cellular Phone Services/Pager Request Authorization and Change Form PDF N/A  
Cellular Telephone User Acknowledgement PDF N/A  
Conference Authorization Form (DPH Travel Workbook) XLS, 547 KB 10/06/11 Conference authorization form for workshops, seminars, training courses, etc. Download 2011 workbook containing forms for travel reimbursement and tab to the form you need.
DPH Six Forks Campus ID/Card Building Access Badge Request PDF, 17 KB 07/12/11 Badge request form for DPH Employees on Six Forks Campus.
DPH Access Badge/Card Request (Downtown) DOC N/A Badge request form for DPH Employees located in downtown Raleigh facilities; NOT for Dix Campus (Royster).
DPH Dix Campus Identification (ID) Badge/Swipe Card Request Form DOC, 97 KB N/A DPH Employees located on Dix Campus (Royster); DIRM form.
State Property Incident Report external link DOC N/A For use by state department head to report to the Director of the State Bureau of Investigation information or evidence of an attempted arson, damage to, theft from or theft of, or embezzlement from, or misuse of any State owned, personal property, buildings or other real property.

 Budget

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Budget Revision Worksheet XLS, 68 KB 12/10/10 Budget revision worksheet.
Cost Allocation Plan (CAP) Update Request DOC, 60 KB 01/11; Last Upload 03/03/11 Form used by the Cost Accounting Branch in establishing and maintaining the Cost Accounting Plan; documents the initiation of cost centers (RCCs) as well as changes to existing centers.
Cost Allocation Plan (CAP) Update Request Instructions DOC, 26 KB 02/08 Instructions for completing the Cost Allocation Plan (CAP) Update Request.
DPH Business Operations Meeting Agenda Template DOC, 91 KB 09/23/10  
Fixed Asset Input Form (FAS-1) HTML N/A DHHS Form for inventorying fixed assets.
Fixed Asset Input Form Instructions PDF N/A Instructions to DHHS form for inventorying fixed assets.
ITS E-Billing Change in Department Code DOC, 27 KB 06/17/2011 Form for Changing ITS E-Billing Department Codes.
ITS E-Billing for Adding/Deleting Users DOC, 30 KB 06/17/2011 Form for Requesting New ITS E-Billing Users or Adding, Deleting, or Changing ITS E-Billing Users.
Review Meeting Summary DOC, 33 KB 07/31/09; Last Upload 09/28/09  
Reclassification Forms with Instructions XLS, 52 KB 06/14/11 Workbook that includes forms for journal voucher reclasses, contract payment reclasses and other reclasses.

 Contracts

 Grants Management

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Form 606A: Notification of Application for Grant Funds/Awards XLS N/A State agencies are required by statute (G.S. 143C-7-1) to notify the Office of State Budget and Management (OSBM) of all applications made for grant funds and/or other funds that require an application.
606A Instructions: Instructions for Reporting Grant Applications/Awards PDF N/A Line-by-line instructions for Form 606A
SF 424: Application for Federal Assistance PDF N/A From grants.gov website
SF 424A: Budget Information - Non-Construction Programs PDF N/A From grants.gov website
SF 424A Example and Instructions DOC, 390 KB 01/22/09 SF 424A example provided by DPH
Cost Allocation Plan (CAP) Update Request DOC, 60 KB 01/11; Last Upload 03/03/11 Form used by the Cost Accounting Branch in establishing and maintaining the Cost Accounting Plan; documents the initiation of cost centers (RCCs) as well as changes to existing centers.
DPH Business Operations Meeting Agenda Template DOC, 91 KB 09/23/10  
Patient Protection and Affordable Care Funding DOC, 32 KB 07/2010 Required form for grants related to PPACA funding.
Request for Allocated Overhead Estimate for Grant Applications XLS, 18 KB 03/09/12 N/A

 Human Resources

 Motor Fleet

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Accident Reporting Form/Vehicle Accident Report PDF N/A Motor Fleet Management's vehicle accident reporting form.
DOT Gasoline Facilities/Automated Fuel Sites HTML N/A JPG map of automated fuel sites in NC.
DPH Car Wash Log XLS, 25 KB 04/12/11 DPH car wash log form for Motor Fleet Vehicles.
State Property Incident Report external link DOC N/A For use by state department head to report to the Director of the State Bureau of Investigation information or evidence of an attempted arson, arson, damage to, theft from, or theft of, or embezzlement from, or misuse of any State owned personal property, buildings or other real property.
Travel Log XLS, 22 KB N/A Motor Fleet Management Form FM-12e

 Purchasing

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Correction Enterprises Print Order Form (DC 258) DOC N/A Complete for publication print orders.
Fixed Asset Input Form (FAS-1) HTML N/A DHHS Form for inventorying fixed assets.
Fixed Asset Input Form Instructions PDF N/A Instructions to DHHS form for inventorying fixed assets.
N.C. DHHS Publication Review (PA-2) PDF N/A Form to initiate final signoff for all printed and Web materials created within DHHS. Call 707-5053 to talk with your Public Information Officer.
Request for Purchase Exception XLS, 25 KB 09/15/09 Subject to the OSBM July 24, 2009 Budget Management Restrictions Memorandum for Fiscal Year 2009-2010.
Telecommunications Cable Service Request (TO-4) DOC N/A Request cable services from ITS.
Telephone Order Service Request (TO-5) DOC N/A Request telephone services from ITS.
Telephone Order Service Request (TO-5) Instructions DOC N/A Instructions for Form TO-5 to request telephone services from ITS
Procedures for Spending Funds PDF, 15 KB 09/12/11 Chart for procedures and applicable forms.
DPH Purchase Request Form XLS, 43 KB 10/05/09; Replaced 10/07/09 DPH Purchase Request form used for ordering supplies, materials, and other equipment. When downloading, a box may appear with an “ok” button near bottom of box; click the button to utilize form.
DPH Purchase Request Form Instructions PDF, 39 KB 10/02/09 Instructions for using the DPH Purchase Request Form (see above).

 Records Management

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Public Records Series Listing DOC or PDF N/A Complete if a schedule needs to be developed and if a schedule needs to be updated.
Records Retrieval Form PDF N/A Use to request records stored at the State Records Center or other storage facilities.
Request for Disposal of Unscheduled Records PDF, 145 KB N/A Approval must be obtained to destroy records not listed on a schedule.

 Risk Management

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
Conflict of Interest PDF, File available on external web site N/A N/A
Federal False Claims Act Education Employee Notice DOC, 30 KB 04/08; Last Upload 08/08/11 N/A

 Travel

Form Format, Size (if DPH file) Last Modified* (if DPH file) Notes
DPH Travel Workbook
  • Conference Authorization Form
  • Conference Authorization Additional Speaker Attachment
  • Authorization of Fees for Expert Speaker
  • Reimbursement of Travel and Expenses Incurred in the Discharge of Official Duty
  • Non-State Employee Reimbursement of Travel and Other Expenses
  • Subsistence Rates
 XLS, 547 KB 10/06/11 Workbook containing forms for travel reimbursement for 2011. Download workbooks and tab to the form you need.
Budget/Travel Authorization Form (BDA) DOC, 24 KB 05/07 DHHS travel authorization form.
Employee Travel Advance Request Form Excel, 25 KB 07/08 Submit at least 5 days before travel.
Payment Verification Form DOC N/A Direct deposit of travel reimbursement (NOT monthly payroll).
Procedures for Spending Funds PDF, 15 KB 09/12/11 Chart for procedures and applicable forms.
Request for Travel Exception XLS, 18 KB 09/15/09 Subject to the OSBM July 24, 2009 Budget Management Restrictions Memorandum for Fiscal Year 2009-2010.